A ‘culture of fear’, anxiety and bullying existed within maternity unit at Shrewsbury and Telford Hospital NHS Trust (SaTH), with staff fearing cosequences if they raised their concerns, the Ockenden Review has found.
Donna Ockenden’s independent review was told by staff that worker shortages were compounded by a culture where team working was “suboptimal”, which the review finds “contributed to many preventable incidents and adverse outcomes”.
The review, published yesterday, concluded that a lack of staff and training were the main reasons for failures at SaTH and led to the avoidable deaths of more than 200 babies and nine mothers.
The report says: “The Trust consistently demonstrated negative behaviours and practices, resulting in many staff learning to accept poor standards as it became the cultural norm; this constitutes organisational abuse.
“It is imperative to ensure the ‘culture’ within all healthcare settings is one that promotes openness, transparency and the psychological safety to escalate concerns. Yet the review team found evidence of disempowerment, with staff encouraged not to complain or raise awareness of poor practice within both personal and professional capacities.”
Staff said they were made to feel as if they were “causing trouble” if they went to HR about their concerns.
One said: “We were bullied, everything was done under the guise of ‘clinical need’ or ‘your contract says.’ We had issues with pay being withheld, managers not happy to reconcile hours/wages. The on-call rotas and change lists were both used as bullying tools. [An] entire team of five experienced midwives left the Trust in less than 18 months.
“I tried to raise a concern and instead of being listened to I was referred straight to occupational health. It seemed that as I dared raise a concern I must obviously be mentally unwell.”
The same staff member said that “cliques” existed within the maternity team that “[made] life hell”. They said it was difficult to speak up about their concerns because “life gets made very difficult” afterwards.
Some spoke of a bullying culture within the leadership team, which the review found was not confined to the senior maternity management team but the entire SaTH management structure.
One said: “I didn’t realise how bad things were in SaTH until I left. The bullying culture from top down breeds bullying.”
The report says: “Whilst it is of equal importance for all staff within maternity settings to demonstrate positive behaviours in their everyday practice, it is vital that leaders, such as the labour ward coordinator and senior obstetricians, are acutely aware of their own behaviour and how this influences other members of the wider team.
I tried to raise a concern and instead of being listened to I was referred straight to occupational health. It seemed that as I dared raise a concern I must obviously be mentally unwell” – a former SaTH employee
“Where negative workplace practices or behaviours are identified, leaders should ensure they take proactive steps to support individuals, address concerns and prevent the creation of a systemic negative culture similar to that described by staff at the Trust.”
Staff spoke of trying to make changes to the way the team operated and of escalating concerns, “but every process we used was set up not to acknowledge our voices or the problems we were highlighting. We were ignored and made out to be the problem but ultimately we failed to make ourselves heard.”
However, the review found evidence from the Trust, covering 2013 to 2016, that showed the local leadership had “identified and escalated workforce issues” and “business plans had been drawn up to increase consultant and middle grade staffing”.
Lack of accountability
The report says: “There is a picture of external, independent and internal reports not being critical of clinical leadership at the Trust. However, the review team is concerned that even where recommendations were made, there is no evidence of who was accountable for their implementation or who, within the context of leadership, was responsible for maintaining oversight of these.
“Because of this, there was no effective strategy for meaningful change within maternity services at the Trust which further perpetuated the cycle of harm to women and families accessing maternity services at the Trust over an extended period of time.
“Staff who are currently employed in maternity services at the Trust and who engaged with the maternity review team as recently as early 2022 told us of a fear of speaking out in maternity services that persist to the current time. This is of very significant concern to the review team and has been shared with the Trust in advance of publication of this report.”
Louise Barnett, chief executive at Shrewsbury and Telford Hospital NHS Trust said: “We know that we still have much more to do to ensure we deliver the highest possible standard of care to the women and families we care for.
“Now that we have received the final report, we will approach the requirements with the focus and resolve we brought to the initial recommendations [from December 2020].
“We owe it to those families we failed, those we care for today and in the future, and our valued colleagues providing that care, to continue to make the necessary improvements so we are delivering the best possible care for the communities we serve.”